[ENA Annual Conference - Evidence-based Practice Presentation] Purpose: The purpose of this study is to improve compliance of the hospital documentation policy. A routine chart audit revealed inadequate and inconsistent documentation on the Trauma resuscitation flow sheet. In response to this finding the current policy was redistributed among all Emergency Department nurses. Initially there was no improvement following the dissemination of the policy. A change in culture was then initiated involving both administration and the bedside nurse. Nursing as a whole was empowered to tackle the responsibility of peer chart auditing. This revealed a dramatic increase in compliance with hospital documentation policy.

Methods: A systematic chart review was conducted using a Chart Audit Tool. The findings revealed severe documentation deficiencies. Kanter's Theory of Empowerment was used to implement a change agent in the emergency department's documentation practice. Nursing empowerment was achieved by allowing greater access to information, education, and support of peer growth. Nurses performed chart reviews and provided real time feedback to their colleagues.

Results/Outcomes: When nurses were given the autonomy to perform peer to peer audits with immediate feedback, and education, the compliance to hospital policy significantly increased. Most audited areas showed a 20-40 % improvement, while a number of noted areas improved by as much as 60%. These results continue to be monitored and early data show sustainability of compliance.

Implications: Empowerment as a group attribute, proved to be a far more effective tool than individualized education. This strategy led to ownership of the issue by nursing staff resulting in a dramatic improvement in compliance. A truly empowering environment for nurses was used to foster mutual professional relationships, increase communication and collaboration to achieve organizational goals.

<table><tr><td colspan="2" class="item-title">Nursing Empowerment: Transforming Emergency Department compliance with hospital documentation policy</td></tr><tr class="item-sponsor"><td class="label">Conference Sponsor:</td><td class="value">Emergency Nurses Association</td></tr><tr class="item-year"><td class="label">Conference Year:</td><td class="value">2010</td></tr><tr class="item-author"><td class="label">Author:</td><td class="value">Broughton-Miller, Kimberly, ARNP, MSN</td></tr><tr class="item-institute"><td class="label">P.I. Institution Name:</td><td class="value">University of Louisville Hospital - Trauma Institute</td></tr><tr class="item-author-title"><td class="label">Title:</td><td class="value">Trauma Nurse Practititioner</td></tr><tr class="item-address"><td class="label">Contact Address:</td><td class="value">530 South Jackson Street, Louisville, KY, 40202, USA</td></tr><tr class="item-phone"><td class="label">Contact Telephone:</td><td class="value">502-562-4090</td></tr><tr class="item-email"><td class="label">Email:</td><td class="value">kimbbro@ulh.org</td></tr><tr class="item-co-authors"><td class="label">Co-Authors:</td><td class="value">Chrissi Doyle, RN; Michelle Frisbie, ARNP-C, MSN;Karina Pentecost, ARNP-BC, MSN; Jodi Wojcik, ARNP-C, MSN</td></tr><tr><td colspan="2" class="item-abstract">[ENA Annual Conference - Evidence-based Practice Presentation] <br/>Purpose: The purpose of this study is to improve compliance of the hospital documentation policy. A routine chart audit revealed inadequate and inconsistent documentation on the Trauma resuscitation flow sheet. In response to this finding the current policy was redistributed among all Emergency Department nurses. Initially there was no improvement following the dissemination of the policy. A change in culture was then initiated involving both administration and the bedside nurse. Nursing as a whole was empowered to tackle the responsibility of peer chart auditing. This revealed a dramatic increase in compliance with hospital documentation policy. <br/><br/>Design: Evidence based, Quality assurance project<br/><br/>Setting: An Academic Regional Level 1 Trauma Center<br/><br/>Participants/subjects: All Emergency Nurses employed at an Academic Regional Level 1 Trauma Center.<br/><br/>Methods: A systematic chart review was conducted using a Chart Audit Tool. The findings revealed severe documentation deficiencies. Kanter's Theory of Empowerment was used to implement a change agent in the emergency department's documentation practice. Nursing empowerment was achieved by allowing greater access to information, education, and support of peer growth. Nurses performed chart reviews and provided real time feedback to their colleagues. <br/><br/>Results/Outcomes: When nurses were given the autonomy to perform peer to peer audits with immediate feedback, and education, the compliance to hospital policy significantly increased. Most audited areas showed a 20-40 % improvement, while a number of noted areas improved by as much as 60%. These results continue to be monitored and early data show sustainability of compliance. <br/><br/>Implications: Empowerment as a group attribute, proved to be a far more effective tool than individualized education. This strategy led to ownership of the issue by nursing staff resulting in a dramatic improvement in compliance. A truly empowering environment for nurses was used to foster mutual professional relationships, increase communication and collaboration to achieve organizational goals. <br/></td></tr></table>

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dc.date.available

2011-10-27T10:26:59Z

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dc.date.issued

2011-10-17

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dc.date.accessioned

2011-10-27T10:26:59Z

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dc.description.sponsorship

Emergency Nurses Association

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